Better Choice Home Health Application

New Hire Application

''Better Together"
What position are you applying for?
Personal Information
Name*

First NameLast Name
Phone Number
Email*
example@betterchoicehomehealth.com
SNN
xxx-xx-xxxx
DOB*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have a US Driving License*

YesNo
US Driving License File Upload*

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Are you a U.S. citizen or authorized to work in the U.S ?*

YesNo
If applicable, please detail any restrictions:
Emergency Contact
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number *
Please enter a valid phone number.
Relationship*
Next of Kin?

YesNo
Position Information
What is your desired employment?*
What is your desired pay?*
Monthly
What is your available start date?*

MonthDayYear
Date
How many years of experience do you have working for a Medicare-Certified Home Health Agency? If N/A, please enter "0"
Ex:23
Do you presently have a non-compete clause with another agency that might affect your employment at Better Choice Home Health?

YesNo
Is there now or has there ever been a claim or suit against you for professional negligence or any other suit or action

YesNo
Have you completed a level 2 background screening?

YesNoNot sure

Employment History

Professional Registration(s) or License(s) Held

Language Spoken (Check all that apply )

Education Background

What is your availability for each day ? Select "none", "all day" or "flexible

References
Reference
Reference
Reference
Please upload your Resume here.*

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The above information is being provided in this application for employment for contractual work is true, correct and complete. I also understand that discovery of any misrepresentation or omission of facts herein will be cause for my immediate termination of contractual work. I further understand that acceptance of an offer of employment does not create a contractual obligation upon the employer to continue to employ or contract with me in the future. The employer or employee can terminate their relationship for any reason or no reason at all. I understand that if accepted for employment I will be working for Better Choice Home Health
at client's home as a part time, per diem, or seasonal employee. I further understand that as a temporary employee, I cannot accept employment with the client to whom I am assigned or the client's family directly or indirectly. I also understand that I will be asked to sign a contract agreement outlining this statement. Any and all information I learn while working for a client is to be kept confidential
Date

MonthDayYear
Date
Signature

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Thank you for your interest in joining our team at Better Choice Home Health. Once you have completed the form above in its entirety, click "Submit" below and a member of our team will be in contact with you.
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New Hire Application